Employers Balk at High Cost Of High-Tech Medical Care

By MILT FREUDENHEIM, Special to The New York Times

Published: April 29, 1990

PITTSBURGH—
In a dramatic illustration of the way rapid advances in medical care in the United States sometimes collide with the will to pay for them, an employer is objecting to a $1.25 million bill for a worker's spouse who became the first person to receive a new heart, liver and kidney in the same operation.

The 26-year-old patient, Cindy Martin, was an ebullient former high school cheerleader and executive secretary from Archbald, Pa. She died March 26 after almost four months in intensive care at Presbyterian University Hospital here.

''They did everything they could,'' said her husband, John. ''They tried to make her life better. But she suffered for four months in the hospital and nothing was really accomplished.''

Mrs. Martin was covered under the health insurance of her husband, a 31-year-old engineer at the Loral Corporation, a military contractor. Loral repeatedly declined to comment on the case, and the insurance company that administers Loral's health plan will say only that payment is being withheld because it is not satisfied with the billing information provided by the hospital.

Growing Number of Challenges

But physicians, benefits consultants and ethicists say a growing number of challenges to medical bills are part of a revolt by employers against soaring health care expenses that erode their profitability, competitiveness and ability to raise wages.

They say employers are increasingly asking whether they are overpaying for medical care, and even questioning whether in some cases the enormous cost of an operation might outweigh the benefits when the chances of prolonging a life seem small.

Most experts agree that taking heroic measures with little thought of costs is the American way of delivering health care, at least for those with comprehensive insurance. Economists estimate that advances in high-technology medicine contributed at least one-fifth of the 10.1 percent growth last year in spending on health care, costs that the Commerce Department says will exceed $660 billion in 1990. In 1980 such spending came to $248 billion.

The issue is only expanding, what with expensive advances that include transplants of not only organs but also bone marrow, whose supply is virtually unlimited, in contrast to organs. Other costly advances include heart bypass operations, computerized diagnostic scans and genetically engineered drugs.

While heroic medical efforts are well intended, some experts wonder whether, in cases where the chances of success are small, the money might better be used in ways that might benefit more people. Among them: preventive health measures like vaccinations and prenatal care, and cleaning up the environment.

Indeed, some countries like Britain and Canada and states like Oregon are trying to give priority to primary care. But where such policies are practiced, expensive high-technology medicine is rationed by budget constraints on hospitals and doctors.

Elsewhere, the ability of patients or their insurance companies to pay for costly medical care has rationed such care.

'Rationing by Price, Excluding the Poor'

''We have always been rationing by price, excluding the poor,'' said Dr. William B. Schwartz, a professor of medicine at Tufts University. ''The new phenomenon is non-price rationing, where you have Blue Cross but you can't get it anyway,'' he said, referring to certain types of health care.

In this country, a few experts would like to see guidelines that would determine when an operation's cost is not warranted, given its chance of success.

''We need an accountable body that could issue some sort of rules,'' said Arthur L. Caplan, who heads the University of Minnesota's Center for Biomedical Ethics. He suggests a ''government commission, which can come up with policies and guidelines that would govern experimental and innovative medical interventions.''

But Gail Wilensky, an economist who heads the Federal Medicare and Medicaid programs, said it would be ''very difficult, if not impossible, for this country to try to set up rules about who should not be able to have the use of medically beneficial technologies.''

The case of Cindy Martin encapsulates the difficulty of deciding not to go ahead with an attempt to save a life, even an extremely costly effort.

Mrs. Martin, who came from a family plagued by early deaths associated with heart disease, had already undergone a heart transplant in October 1985 at the hospital, a unit of the University of Pittsburgh's medical center. That procedure, which generally costs about $150,000 with follow-up care, was covered by her employer, the McKinney Products Company, a Scranton hardware maker.

John Martin said that after the first transplant, his wife returned to work for a time but that starting in 1987 she was ''constantly in and out of the hospital.''

Her doctors said that her heart was weakening and that a drug that transplant patients must take was destroying her liver and kidneys. ''She was a patient dying, with three organs failing,'' said Dr. Thomas Starzl, a prominent transplant surgeon.

He said the hospital had a commitment to Mrs. Martin in part because it provided her first transplant. ''The options were wash your hands or not abandon her,'' Dr. Starzl said.